6 Questions (and Answers) about Value-Based Care

April 19, 2022 · Andy Reynolds

Recently a journalist asked NCQA leaders for a background briefing about value-based care. Here are the reporter’s six questions and our responses.

1) What are some of the main difficulties in advancing value-based care and its respective alternative payment models?

• Getting straight on who does what: Defining the entity that will accept and distribute payments is key. This is especially tricky when the infrastructure to accept and distribute payments does not exist. This is why ACOs, federally qualified health centers and patient-centered medical homes have been the focus of alternative payment models (APM) development.
• Oh, to be a payvider: Payers and providers may find it hard to interact and create “payviders”—organizations like Kaiser Permanente or Geisinger that are both health insurers and delivery systems.
• Updating quality measures: We need to adapt quality measures to support performance-based payments. Improving digital health data infrastructure would make measurement more accurate and more timely.

 2) What are some surprising headwinds that are currently slowing the pace?

• Consolidation: On one hand, consolidation can enable investments in health data systems or other IT infrastructure. Also, larger organizations can take on more financial risk—an important part of developing APMs. On the other hand, consolidation reduces competition. The remaining, consolidated organizations have leverage to set their own terms and resist efforts by payers and employers to make new APMs.
• Lack of standardized data exchange: Standardizing data exchange has been slow. The HITECH Act digitized information. But only now are we beginning to see rules and standards that will facilitate the flow of data between organizations and with patients.
• Access and network adequacy: Getting primary care and specialists in rural or depressed areas to commit to performance requirements is tall order for anyone trying to build and meet federal or state network adequacy and access requirements.

3) How is the lack of data available impacting things? What can be done to help improve this?

• Problem: Without accurate data about providers, services and timelines, it’s hard to meaningfully measure nuances of how patients and their conditions are identified and managed over time.For example, it’s hard with current data to follow a cancer patient from first symptoms through diagnosis, staging, complex treatments and follow-up after cure. The same is true of all chronic conditions.In short, data we have don’t tell us as much as we would like to know about decisions, referrals and responses to treatment.

• Solution: NCQA is optimistic that new rules from ONC requiring organizations to share data can create opportunities that could be as transformative for health care as data exchange has been for retail, travel and banking.

4) How does the variety of provider costs play into this all? APMs obviously don’t account for that or will be slow to catch up with that reality. What can be done to improve the APM system?

• Attribution: The first step is identifying the responsibility and contribution of each provider within a team. Who has done what for the patient? How are they compensated for their efforts on the patient’s behalf?
• Standardization of EHRs: Lack of standardization increases complexity and costs. For example, ACOs can end up with different systems for different practices they acquire.

5) Why is patient satisfaction a key to successful VBC and what happens when a patient doesn’t buy in?

• Seeing is believing: Value-based care will succeed when patients know they have access to care that’s better, more convenient and costs them less.
• Buy-in begins with costs: Reformers seeking patients’ support should focus first on costs because costs are a perennial complaint of patients. But don’t forget people care about quality too. They won’t settle for less expensive care if they’re not sure it’s at least as good as more expensive care.

6) What is the key to making value-based care models successful?

• Let in the new: Allow new entrants to provide access to convenient, high-quality care at a lower cost. Community health centers and the Veterans Administration are good models that could be adapted for other populations.
• Start with Medicare: Medicare Advantage is a good place to start because those patients use a lot of care and face many costs (especially if they have high deductibles). The Center for Medicare & Medicaid Innovation (the Innovation Center) at CMS is  especially important for identifying APMs that could work in the private sector.
• Steady money for providers: During the pandemic, providers reimbursed by fee-for-service payments took in less money as in-person visits dropped. Most APMs create steadier revenue streams while enabling providers to use the most effective modes of delivering care.